With so many developments in the field of psychotherapy, so many integrations, innovations, and shifts from evidence-based to common factors, its hard to keep up! Therapy On the Cutting Edge is a podcast with hour long interviews of clinicians that are creating, innovating, researching, developing, and perfecting treatments for clients.
To Hospitalize or Not to Hospitalize, the Question Most Therapists Struggle with in Helping Clients with Suicidality
In this interview, Dave discusses his career in researching suicide and how Marsha Lineman encouraged him to go beyond his assessment work to create an intervention for therapists working with clients who are suicidal. He discusses how many therapists struggle to know how to effectively assess suicide risk and intervene in a manner that can build the therapeutic relationship as well as keep clients safe. He explains that due to lack of training, knowledge of evidence-based interventions, and fear, therapists often jump to hospitalizing their clients, when it may not be necessary, and he challenges the overall utility and effectiveness of hospitalization altogether. Dave discusses his clinical tool and intervention, the Suicide Status Form (SSF-4) and his Collaborative Assessment and Management of Suicidality (CAMS), which have been found to decrease suicidal risk in patients through randomized controlled trials. He explains that therapists can effectively treat suicidality through collaboration, being clear and transparent on the limits of confidentiality and what may lead to a hospitalization. His intervention helps reduce access to lethal means as well as the value of identifying and treating patient-defined "drivers" for suicide, which research shows leads to decreasing hopelessness while increasing hope. The topics of suicidal ideation vs. suicidal intent are discussed and how ideation in itself is sometimes a form of coping. He speaks to the most feared situations where the therapist is not sure if the client can be sufficiently stable for outpatient care, and he addresses cases in which clients who take their life despite all clinical best efforts. Dave encourages therapists to become more competent in suicide assessment and treatment, because even though clinicians may screen for suicide when accepting patients, it is inevitable that they will have clients who are suicidal. He argues that suicide risk being "not something I work with,” is a problematic stance as it reflects an unwillingness to work with the one fatality of mental health.
David A. Jobes, Ph.D., ABPP, is a Professor of Psychology, Director of the Suicide Prevention Laboratory, and Associate Director of Clinical Training at The Catholic University of America. Dave is also an Adjunct Professor of Psychiatry, School of Medicine, at Uniformed Services University. He has published six books and numerous peer-reviewed journal articles. Dave is a past President of the American Association of Suicidology (AAS) and he is the recipient of various awards for his scientific work including the 1995 AAS “Shneidman Award” (early career contribution to suicidology), the 2012 AAS “Dublin Award” (for career contributions in suicidology), and the 2016 AAS “Linehan Award” (for suicide treatment research). He has been a consultant to the Centers for Disease Control and Prevention, the Institute of Medicine of the National Academy of Sciences, the National Institute of Mental Health, the Federal Bureau of Investigation, the Department of Defense, Veterans Affairs, and he now serves as a “Highly Qualified Expert” to the U.S. Army’s Intelligence and Security Command. Dave is a Board Member of the American Foundation for Suicide Prevention (AFSP) and serves on AFSP’s Scientific Council and the Public Policy Council. He is a Fellow of the American Psychological Association and is Board certified in clinical psychology (American Board of Professional Psychology). Dave maintains a private clinical and consulting practice in Washington DC; clinicians can get trained in the CAMS evidence-based treatment at https://cams-care.com/.
Understanding the Schizophrenia Prodrome and Early Intervention for Psychosis
In this episode Rachel discusses her career in treatment and research of schizophrenia, and particularly, her research at the University of California, San Francisco, studying the prodromal phase of schizophrenia, which refers to early signs and symptoms, in an effort to detect and prevent the development of a full blown disorder. She explains the differences between prodromal symptoms and the Clinical High Risk Syndrome (CHR), and how there are three main aspects: the presence of delusions and hallucinations, the level of the individual's conviction that the delusions or hallucinations are real, and the level of distress or impairment. She points out that only 25% of people develop psychotic disorders within 2.5 years after diagnosis of the CHR syndrome. She discusses the Coordinated Specialty Care Model that involves medication, Cognitive Behavioral Therapy for psychosis, family support and psychoeducation, case management, and supports to keep the individual on track with school or work. She talks about the advancements in psychiatric medication and discussed elements of CBT for psychosis. She talks about the role of the family and supporting the family through this process, and how the concept of Expressed Emotion and past theories about families with schizophrenia (e.g., refrigerator mother), have done damage in the conceptualization of working with families. She discussed the need for psychoeducation, as well as understanding the interactional patterns that happen between family members as there is a great deal of fear, helplessness, and shame. She discussed how clinicians in practice who are unfamiliar with psychosis should manage their own reactions of fear or overwhelm, as expressing these reactions may lead their client to shut down or avoid seeking support for their symptoms. She reassured that working with psychotic symptoms is very similar to working with other issues in therapy. We discussed validating the client, being curious about their experience, and getting consultation, as many clinicians are unfamiliar with psychosis, or only received training in intensive situations like hospital settings, so have a fatalistic view of these diagnoses. What the clinicians don’t see is that generally, 1/3 of clients recover on their own, for 1/3 medication works, and its only 1/3 that struggle with severe, chronic psychosis. Many people may live with symptoms their whole life, but be happy, healthy and functioning, so the reduction of symptoms may not be the main goal of treatment.
Rachel Loewy, PhD, is a clinical psychologist currently working as a Professor of Psychiatry at the University of California, San Francisco. Along with teaching, Rachel has developed clinical programs to diagnose and treat early psychosis, and has led many research studies, primarily focused on early identification and intervention in schizophrenia. Currently, she is a co-investigator on a research project dedicated to building a California early psychosis network that would input thousands of patients' data into one network hoping to create a better system that allows for improved intervention effort. Alongside her research, Rachel has many publications regarding her work that have all been compiled at https://profiles.ucsf.edu/rachel.loewy. These publications focus on various studies regarding schizophrenia and psychosis, such as evidence-based practices for early intervention in psychosis particularly in community settings.
Helping Veterans Navigate the Dual Systems Paradigm of Returning Home to Families Through Being with Their Experience and Letting the Connection Determine the Treatment Modality, Rather Than a Protocol
In this episode, Keith talks about his unique experience of being deployed in Iraq with his wife, and after a roadside bomb (IED) attack, she struggled with PTSD. He discussed how after she received treatment through the military mental health system, which was retraumatizing, he started taking classes in Psychology and learned all he could about trauma, and together they worked through her PTSD. This lead him to go on to obtain a doctorate in psychology, and work with veterans and their families specializing in combat trauma and military sexual trauma. He explained that soldiers are trained to turn all of their vulnerable emotions into aggression, because that is what is needed to survive in battle, and this makes it difficult for soldiers to transition back into their family system and larger society. Additionally, in the military, they form strong bonds with their fellow soldiers, and between conditioning, the group think, and the experiences that the soldiers go through together, it makes some feel that no one else understands their struggle which leads to suffering alone. This creates a dual family systems paradigm, the differences between the military system’s culture and the family’s system’s culture, leaving veteran's feeling disconnected from both families. He discussed the importance of connecting with the individual, being with their experience, and how this can be very hard for clinicians as working with veterans with trauma session after session can lead to vicarious trauma and compassion fatigue. He discussed his work with The Hume Center, with the chronically homeless population and working with severe mental illness, and how there is a great deal of intersectionality between homelessness and veterans. He discussed the importance of meeting the client where they are, and then finding what approaches might fit best for them, rather than using a top down approach such as trying to fit them into an evidence based scripted protocol. We discussed a rather successful program for Veterans in Oakland at the Oakland Vet Center, where staff had been working there for many years, as opposed to other programs where there is high turnover both in clients and in clinicians. One of the aspects that seemed to make it successful was the connections built through the community of clients. He discussed how clients who had been doing group work there would come to his PTSD 101 workshops just to see their friends. We discussed how engagement, whether with the clinician, or the community of clients was so significant in engagement for mental health services.
Keith Bonnes, Psy.D. is a clinical psychologist and an Air Force (deployed Army) blue to green veteran of the Iraq war. Keith has worked extensively with veterans and their families and now works at The Hume Center in the San Francisco Bay Area East Bay https://www.humecenter.org, which as a Non-profit provides a range of community based treatments including full service partnership with homeless individuals, outpatient services and partial hospitalization programs and many other community based services and programs. He is also a trainer with The Hume Center working to help develop the clinical skills of early career clinical trainees and provide an exceptional training experience as a behavioral training center. He works from a humanistic, client centered, phenomenological approach, meeting the client where they are, and connecting with their experience, and then integrating modalities of treatment and interventions to fit for the clients perspective of the world. Keith uses Maslow’s Hierarchy of Needs as a building principal along with cultural humility in his work with clients to ensure a holistic approach to the clients experience is considered.
Increasing Your Effectiveness with Clients Using The Experts Themselves, Your Clients!
In this interview, Scott discusses how he came to his work focusing on Feedback Informed Treatment and deliberate practice. He discussed how when working with the Solution Focused Therapy founders, independent research found that the approach was effective, but not so significantly more effective than other approaches. He explained how this was surprising to him, and when he looked into it more, he found this finding was true when applied to all theories and techniques. He discussed his drive to improve as a clinician himself and his work with Michael Lambert and Lynn Johnson in looking at the common factors related to outcome and using client feedback to improve alliance and thus outcome. We discussed how continuing education is often focus on theory and technique, and how if a clinician would like to improve their effectiveness with clients, they need to focus on improving their relationships with clients. He discussed learning about Anders Ericsson's research related to deliberate practice, and how clinicians can use this to improve their work with clients. We discussed how research is often focused on symptoms, but it is actually the individual's functioning that is more important as functioning is often what brings clients into treatment, rather than symptoms. He explained that when working in drug and alcohol treatment, he often wondered why the clients had not sought treatment earlier, and it was often an effect on their functioning (e.g., losing their partner, losing their job) that propelled them into treatment. Scott discusses how often when people consult with him, he always returns to why the client is in therapy and what they want out of it, which many therapists forget about as they turn their attention towards the symptoms.
Scott D. Miller, Ph.D. is the founder of the International Center for Clinical Excellence, an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavioral health services. Scott conducts workshops and training in the United States and abroad, helping hundreds of agencies and organizations, both public and private, to achieve superior results. He is one of a handful of "invited faculty" whose work, thinking, and research is featured at the prestigious "Evolution of Psychotherapy Conference." His humorous and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policy makers to make effective changes in service delivery. He is the author of numerous articles and co-author of Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, The Heroic Client: A Revolutionary Way to Improve Effectiveness through Client-Directed, Outcome-Informed Therapy, and Feedback Informed Treatment in Clinical Practice: Reaching for Excellence.
Integrating Questions of Privilege, Oppression and Power in the Therapeutic Encounter
In this episode, Jane discusses her own experience of growing up in a privileged white community and the subsequent development of her career in social justice. That was the beginning of her journey working with different organizations concerning the effects of wide-spread oppression particularly in education in the United States and in Israel at the Hebrew University of Jerusalem. When she became a psychotherapist years later, she realized that her training did not specifically cover the effect of the “isms,” and their relationship to the life experience of clients and their mental health, even though family therapists were trained in systemic thinking and the importance of context. After becoming a Visions consultant, she became more aware of her own privilege and the historic and present oppression others continually experienced. Intersectionality became very important as well because each person usually has some places where they have privilege and some where they are oppressed. How each of us behaves in those different places becomes an important area of exploration, both for therapist and client. Briefly, she discussed three important characteristics that therapists hopefully bring to their work. One is cultural humility, another is authenticity, and the third is a constant awareness of context and privilege and how it intersects with individual and relational mental health. She discussed how the role of therapist itself brings power into the room, and even if there is intersectionality, where there is shared race, gender, sexual orientation or a number of other characteristics, the therapist continues to hold power. She shared her experience in Kosovo dealing with grieving and traumatized families just after 9/11 occurred. She used the term “open listening”, which is a valuable way to be completely present, stay with the person’s experience empathically, while at the same time not losing oneself.
Jane Ariel, PhD, LMFT is a psychologist in Oakland, California, and works with individuals, couples, and families. She has been an adjunct professor at the Wright Institute in Berkeley and has worked also with the Women’s Therapy Center and other institutions in the Bay Area. She is an active member of the American Family Therapy Academy, and works with Visions, a national organization dealing with issues of equity, inclusion, and multiculturalism.
Bridging the Divide Between Couples Therapy and Sex Therapy Using Emotionally Focused Couples Therapy’s Process Orientation and Attachment Focus
In this interview, Lisa and Silvina discuss their path to sex therapy, both being couples therapists trained in Emotionally Focused Couples Therapy. At their weekend Hold Me Tight Workshops for couples, there was never enough time after all the relational work to delve deeply enough into the couple’s sexual relationship; so they dove into deep study over several years and developed an integrative approach, blending the best of sex therapy techniques and the process orientation and attachment focus of Emotionally Focused Therapy (EFT). In the interview, they discuss the relationship between attachment and sex in a couple’s relationship, and how physical connection is so essential to attachment, citing Harlow’s research with the “cloth mother” monkeys as but one example. I invite them to share more about several of the key concepts they cover in their workshop for clinicians, Integrating Sex and Sexuality in EFT Couples’ Work. We discuss the groundbreaking work of Emily Nagosky, who has made accessible to everyone such key concepts as the Dual Control Model of Sexual Response, responsive desire and newer versions of the Sexual Response Cycle model that allow so many more options for couples. They discuss how for many therapists, couples therapy and sex therapy are disconnected, but how powerful the integration of the two can be. We discuss how they use sex therapy behavioral interventions, such as a variety of touch exercises, and process these experiences with the couples through the EFT lens to understand the blocks that get in the way. This integration of an experiential, process-oriented therapy, and behavioral interventions from sex therapy, through an attachment lens helps bridge the divide between couples therapy and sex therapy.
Silvina Irwin, Ph.D., is a licensed clinical psychologist in Los Angeles, and ICEEFT Certified Trainer and Supervisor in Emotionally Focused Therapy for Couples. Under the mentorship of Dr. Sue Johnson, founder of Emotionally Focused Therapy, Silvina offers trainings in LA and other select US and International areas. She is co-founder of the EFT Resource Center in Pasadena, CA, which provides EFT psychotherapy services to the community and offers training and supervision to therapists in Emotionally Focused Therapy. In her psychotherapy practice, Dr. Irwin specializes in working with survivors of trauma and relationship distress. In addition, Dr. Irwin has developed and facilitated workshops for couples who want to deepen and enrich their sexual connection. Dr. Irwin also leads consultation groups with her close colleague Dr. Lisa Blum for mental health professionals all over the country who are refining their skills in integrating sexuality into their couples’ therapy work. Dr. Irwin also offers master classes on working with trauma in couples therapy, and workshops on Vicarious Trauma of therapists, first responders, and the legal and medical community. To learn more about Dr. Irwin, please visit www.drsilvinairwin.com or www.EFTResourceCenter.com.
Lisa Blum, Psy.D. is a licensed clinical psychologist who specializes in promoting healthy couple and family relationships through an attachment lens. Dr. Blum is an ICEEFT-Certified Supervisor and Therapist in Emotionally Focused Couples Therapy (EFT), one of the few research-validated therapies for helping couples and families strengthen relationships and build stronger connections. Dr. Blum is a Co-Founder of the EFT Resource Center in Pasadena, a group private practice, where her work includes individual, couples, and family therapy, and supervision, training, and public speaking on family, marital, and parenting issues. Dr. Blum works with both gay, lesbian, queer and straight individuals and couples, and with adults forming families in novel and creative ways. Since the beginning of her career, Dr. Blum has been involved in teaching, research, and practice in the field of sexuality, and currently co-fa